MONTHLY LABORATORY CONTAMINATION SURVEY
National Institutes of Health Radiation Safety Branch (Bldg. 21/116) RSB 496-5774 or FAX 496-3544 Send original to RSB, and retain copy in lab records for 3 years. Building Suffix Floor Wing Room Rooms Linked on this Survey Survey Date (mm/dd/yy)
TYPE OF COUNTER USED TO ANALYZE SMEARS:
Liquid Scintillation Counter [ ] Gamma Counter [ ] LSC or Gamma Counter Property #:
Indicate radionuclides and activities used since last monthly survey: Activity = Total amount used since last monthly survey.
Isotope Authorized User: Last Name, First Name RSB User Number Phone Number H-3 S-35 C-14 Surveyor: Last Name, First Name RSB User Number Phone Number P-32
Activity (in mCi)
Isotope P-33 I-125 I-131 Cr-51
Activity (in mCi)
Check here if radionuclides were not used this month in all modules represented on this form. [ ] SURVEYOR'S SIGNATURE
SMEAR RESULTS (in dpm/100cm2)
Fill in radionuclides and indicate quantitative smear results in DPM.
DIAGRAM OF LABORATORY: Sketch module(s) and number locations smeared. A minimum of 10 smears must be taken in each module where radionuclides are used, with at least two on the floor. Clearly indicate on multiple-module surveys if any modules had no usage in this month.
DPM = CPM / COUNTER EFFICIENCY PRINTOUT MUST BE ATTACHED! Location
BKG 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Nuclide 1
Nuclide 2
Nuclide 3
REMARKS: Include explanation of actions taken for smears >2,200 dpm/100cm² beta-gamma or >220 dpm/100 cm² alpha.
18 19 20
NIH 88-12 12/99
For detailed instruction on completing the NIH 88-12 form go to http://www.nih.gov/od/ors/ds/rsb/8812instructions.html